Matters of the Heart - Hospice & Palliative CareCenter is ... · MATTERS OF THE HEART Caring for...
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MATTERS OF THE HEART
Caring for Patients with Heart Failure
Mrinalini Joshi, MD MPH
March 23, 2012
Objectives
� Describe trajectory & prognostication of heart failure (HF)
� Review pharmacological and non-pharmacological treatment
� Discuss palliative care role & hospice eligibility criteria
� Management of common symptoms in advanced HF
What is Heart Failure?
Complex Clinical Syndrome
� Structural or functional cardiac disorder
� Impairs ability of ventricle to fill with or eject blood
Characterized By
� Dyspnea
� Exercise intolerance
� Fatigue
� Fluid retention
Epidemiology
Incidence: � 550K new cases/yr
Prevalence: � 5.8 million Americans with symptomatic HF
Morbidity: � 1 million hospitalizations annually
� Most common discharge diagnosis among Medicare beneficiaries
� 80% hospitalized in last 6 months of life
Economics: � Health care $$ = 40 billion/year
Mortality:� 250,000 deaths/yr
� 1 yr mortality comparable to certain cancers
Diagnosis
� Clinical history and exam
� 2D Echocardiogram = Gold standard
� Ejection Fraction (EF)
� Structural abnormalities
� Brain Natriuretic Peptide (BNP) = Good “rule-out” test
Making sense of the terminology!
High output?
Low output?
Backward?
Forward?
Acute ?
Chronic?
Left?
Right?
Systolic?
Diastolic?
Classification
Heart Failure with Reduced Ejection Fraction (HFREF)
…aka Systolic HF
vs.
Heart Failure with Normal Ejection Fraction (HFNEF)
…aka Diastolic HF
HFNEF
� EF > 50%
� Diastolic dysfunction
� Impaired LV relaxation
� Elevated diastolic filling pressures
� Diastolic wall stiffness
� HTN : LV hypertrophy
� DM, Obesity, sleep apnea
� Valvular disease
� Hypertrophic cardiomyopathy
� Restrictive cardiomyopathy
HFNEF
� Females > males
� Majority asymptomatic
� Symptoms similar to HFREF
� Low tolerance to atrial fibrillation or abrupt hemodynamic
changes
� Lower incidence of sudden cardiac death
Disease Severity
� New York Heart Association (NYHA) classification
� American College of Cardiology/American Heart Association
(ACC/AHA) classification
NYHA classification
Class Symptoms
INo limitation of physical activity. Ordinary physical activity does not cause
undue fatigue, palpitations, or dyspnea.
IISlight limitation of physical activity. Comfortable at rest, but ordinary
physical activity results in fatigue, palpitations, or dyspnea.
IIIMarked limitation of physical activity. Comfortable at rest, but less than
ordinary activity causes fatigue, palpitations, or dyspnea.
IV
Unable to carry out any physical activity without discomfort. Symptoms of
cardiac insufficiency at rest. If any physical activity is undertaken,
discomfort is increased.
American College of Cardiology/American Heart Association
Stages of Heart Failure
Stage Definition Patient Description
A High risk for developing HF HTN, CAD, DM, FHx of Cardiomyopathy
B
Asymptomatic HF
Structural heart disease without any symptoms of HF
Previous MI
LV hypertrophy or systolic dysfunction
Asymptomatic valvular disease
C
Symptomatic HF
Structural heart disease with prior or current symptoms of HF
Known structural heart disease
SOB, fatigue
Decreased exercise tolerance
D Refractory, End-Stage HFMarked symptoms at rest despite maximal medical therapy
Objectives
� Describe trajectory & prognostication of heart failure (HF)
� Review pharmacological and non-pharmacological treatment
� Discuss palliative care role & hospice eligibility criteria
� Management of common symptoms in advanced HF
Disease Trajectory
Prognostication
� Challenging � High incidence of sudden cardiac death (SCD)
� Differences in application of treatment guidelines
� Inter-observer differences in assessing NYHA class
� Several models proposed� EFFECT Model
� Heart Failure Survival Score (HFSS)
� Seattle Heart Failure Model (SHFM)
Seattle Heart Failure Model (SHFM)
� Tested primarily in patients with SHF
� Both outpatient and advanced HF patients
� Accurate (?) estimate of 1-, 2- and 3- year mortality
� Predictive of mode of death in ambulatory patients with NYHA
class II-IV
� http://depts.washington.edu/shfm/app.php
Seattle Heart Failure Model (SHFM)
� Age � Statin use
� Gender � Allopurinol
� Ischemic disease � Hemoglobin
� NYHA class � Lymphocyte count
� Ejection Fraction � Uric Acid
� Systolic BP � Sodium
� Use of a K sparing diuretic � Cholesterol
� Diuretic dose/kg
Objectives
� Describe trajectory & prognostication of heart failure (HF)
� Review pharmacological and non-pharmacological treatment
� Discuss palliative care role & hospice eligibility criteria
� Management of common symptoms in advanced HF
Mainstays of Treatment
� Drugs
� Devices
� Cardiac transplant
HF with Normal EF
� Control BP – systolic and diastolic
� Treat hyperlipidemia
� Rate control if in atrial fibrillation
� Caution when using diuretics, ACE-I, CCB and nitrates
� Coronary revascularization in patients with CAD
HF with Reduced EF
� Start with a diuretic if volume overloaded
� Mortality benefit
� Reduced hospitalization rates
� Add drugs with mortality benefit, titrate to target doses
� ACE-I : all patients
� ARBs : if unable to tolerate ACE-I
� BB : NYHA class II, III
� Aldosterone antagonist + diuretic+ ACE-I: NYHA Class III, IV
� + Hydralazine+Nitrate (Bidil) – especially in AA
Target doses
Drug Starting dose Target dose
ACE-I
Captopril 6.25 mg TID 50 mg TID
Enalapril 2.5 mg BID 10-20 mg BID
Lisinopril 2.5-5 mg QD 20-40 mg QD
ARBs
Candesartan 4-8 mg QD 32 mg QD
Losartan 25-50 mg QD 50-100 mg QD
Valsartan 20-40 mg BID 160 mg BID
BB
Carvedilol 3.125 mg BID 25-50 mg BID
Bisoprolol 1.25 mg QD 10 mg QD
Metoprolol ER 12.5-25 mg QD 200 mg QD
Spirinolactone 12.5-25 mg QD 25-50 mg QD or BID
Digitalis
� No mortality benefit but..
� Does provide symptomatic relief� Use after ACE-I/ARBs, BB, diuretics fail to provide relief
� Not recommended as 1st line in � Acute exacerbation
� Systolic dysfunction + Atrial fib
Vasodilators
� Nitroglycerin, Nitroprusside, Nesiritide
� Symptomatic relief in acute decompensation
� Added if symptomatic after maximizing other first line
meds
� In chronic HF, oral nitrate combined with hydralazine
Inotropes
� Dopamine, Dobutamine, Milrinone
� Oral agents associated with increased mortality
� Continuous vs. intermittent infusion for palliation of
symptoms in patients with refractory end-stage HF
� Need for continuous inotrope infusion = poor
prognosis: 20-25% 1 year survival
Adverse Effects
� ACE-I/ARBS� Hypotension
� K retention
� Renal failure
� Cough
� Angioedema
� Digoxin� Cardiac arrhythmias
� GI distress
� Neurological complaints
� BB� Fluid retention
� Worsening HF
� Fatigue
� Bradycardia, heart block
� Hypotension
� Aldosterone antagonists� Hyperkalemia
Bottomline..
� Titrate meds to target dose for maximal benefit –
Survival + Symptom relief
Query 1
When do we discontinue diuretics on end stage heart
failure patients?
� Significant hypotension
� Declining renal function
Query 2
Beta-blockers have to be used “cautiously” in patients
with heart failure. At what point and how should they
be discontinued?
� Significant hypotension or bradycardia
� May retitrate once stable
� Ideal taper 4-6 weeks long…..
� Try some form of taper over a few days
Devices
� Implantable Cardioverter Defibrillators (ICD)
� Reduces risk of sudden cardiac death
� Cardiac Resynchronization Therapy (CRT)
� ↓↓↓↓ mortality and hospitalizations
� Improved QOL
Ventricular Assist Devices (VADs)
� Left, right or BiVad
� Patients with a life expectancy < 2yrs
� Bridge to transplant (BTT)
� Bridge to recovery (BTR)
� Destination therapy (DT)
� Patient not a transplant candidate
� Requires permanent mechanical circulatory support
Ventricular Assist Devices
� High risk surgery with complex post-implant care
� Early complications
� Bleeding
� Sepsis
� Multi-organ failure
� Late complications
� Thromboemblism
� Infection
� In hospital mortality about 27%, 1 yr survival nearly 60%
� Improved quality of life
Query 3
When to turn a LVAD off? Is this is just one more decision
family has to make?
Approaching End of Life - VAD
� Turning off LVAD� Ethically challenging
� LVAD is not a replacement treatment
� Patients have the right to refuse treatment
� Unethical to continue a treatment patient has refused
� Preparedness planning� Psychosocial
� Caregiver concerns
� QOL
� Ethics
Objectives
� Describe trajectory & prognostication of heart failure (HF)
� Review pharmacological and non-pharmacological treatment
� Discuss palliative care role & hospice eligibility criteria
� Manage common symptoms in advanced HF
Role of Palliative Care
� Supportive care� Education and self management
� Communication
� Psychosocial and spiritual issues
� Symptom management
� Decision-making� Preferences for CPR, need for ICD
� Cardiac transplant, LVAD
� Advance directives
Role of Palliative care
Identifying the Patient with End Stage HF
� Marked decline in functional ability and quality of life
� Frequent hospitalizations for exacerbations despite:
� Maximal medical therapy
� Identification and treatment of reversible causes
Approaching End Stage HF
� Educate, educate, educate
� Revisit goals of care
� For patients with ICD - Discuss if and when to turn off
ICD
� If patients opt for LVAD as DT or BTT: preparedness
planning
Current Hospice Guidelines
� NYHA class IV
� Optimal medical management� Patient refuses device (ICD/CRT/LVAD) or transplant
� Patient not a device or transplant candidate
� Supportive but not required� LVEF < 20%
� Treatment resistant, symptomatic arrhythmias
� h/o cardiac arrest or CPR
� Unexplained syncope
� Embolic stroke of cardiac origin
� Concomitant HIV
Query 4
I am curious about maximal medical management of
heart failure patients whose death is imminent due to
another co-morbidity (ex. ESRD and have decided to
forgo dialysis).
� If hypotensive, but still able to take PO meds, cut back instead of
stopping meds
� If death is imminent, will likely need to discontinue meds
contributing to hypotension or circulatory failure
When the Goal is Palliation….
� Optimize medical treatment – known to palliate
symptoms and prolong life
� Diuretics, fluid and salt restriction
� ACE-I/ARBs/BB
� Small, stable changes in BUN/Creat acceptable
� Moderate hypotension OK
� Monitor weight
Objectives
� Describe trajectory & prognostication of heart failure (HF)
� Review pharmacological and non-pharmacological treatment
� Discuss palliative care role & hospice eligibility criteria
� Manage common symptoms in advanced HF
Symptom Burden
� Large proportion of patient families report quality of life (QOL)
as being poor to fair in the last week of life
� The 4 most common symptoms reported by patients/family
members in the last 6 mths of life
� Pain
� Dyspnea
� Fatigue
� Confusion
Symptoms
� Dyspnea and pain : Opioids, Benzodiazepines
� Fatigue/depression: Stimulant (Methylphenidate)
� Sleep disturbance: CPAP/BiPAP
� Anorexia
� Weight loss
� Anxiety: Benzodiazepines
Pain
� Prevalence of pain increases with NYHA class
� 90% of patients with Stage IV HF
� Often described as generalized/diffuse pain
� So far, no HF pain syndrome described
� ? HF + comorbidities
� Undertreated despite known high prevalence!
� Rx mainstays
� Avoid NSAIDs
� Low dose opioids, titrate up as needed
� OA: joint injections
Dyspnea
� Maximize HF medications if tolerated
� Low dose opioids
� Oxygen: only if hypoxic
� Continuous inotrope infusion ($$$ + ↑↑↑↑mortality)
� Nitrates for afterload reduction
� Cochrane review of dyspnea in COPD
� Hawthorn extract
� Breathing training
� Chest wall vibration
Other Symptoms
� Fatigue
� Underlying cause
� Ritalin
� Energy conservation techniques
� DME or adaptation of home environment
� Depression
� Consider Ritalin or an SSRI
� Anxiety
� Benzodiazepines
Summary
� HF is a major public health problem
� Treatment of HF varies by stage
� Prognostication is challenging
� Sudden cardiac death is common and may occur at any time during the course of the disease
� Always attempt to achieve target doses of drugs with proven mortality benefit
� Maximal medical therapy should be continued as long as possible due to palliative benefits
� Educate = empower, ? Action plans
References
� Solomon SD, Anavekar N, Skali H, et al: Influence of ejection fraction on cardiovascular outcomes in a broad spectrum of heart failure
patients. Circulation 2005;112:3738-3744.
� Solomon SD, Dobson J, Pocock S, et al: Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic
heart failure. Circulation 2007;116:1482-1487.
� Kitzman DW, Gardin JM, Gottdiener JS, et al: Importance of heart failure with preserved systolic function in patients N or = 65 years of age.
CHS Research Group. Cardiovascular Health Study. Am J Cardiol 2001;87:413-419.
� Gheorghiade M, Zannad F, Sopko G, et al: Acute heart failure syndromes: current state and framework for future research. Circulation
2005;112:3958-3968.
� Lietz K, Long JW, Kfoury AG, et al. Outcomes of left ventricular assist device implantation as destination therapy in the post-REMATCH era:
implications for patient selection. Circulation. 2007;116:497–505.
� Swetz KM, Ottenberg AL, Freeman MR, Mueller PS. Palliative care and end-of-life issues in patients treated with left ventricular assist devices
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� Goodlin SJ. Palliative care in congestive heart failure. J Am Coll Cardiol. 2009 Jul 28;54(5):386-96.
� Goldfinger JZ, Adler ED. End-of-life options for patients with advanced heart failure. Curr Heart Fail Rep. 2010 Sep;7(3):140-7.
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� Bui AL, Horwich TB, Fonarow GC. Epidemiology and risk profile of heart failure. Nat Rev Cardiol. 2011 Jan;8(1):30-41. Epub 2010 Nov 9.
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